Provider Demographics
NPI:1366502825
Name:MARCIN DENTAL CENTERS PC
Entity Type:Organization
Organization Name:MARCIN DENTAL CENTERS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROSEANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUNENKANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-274-6237
Mailing Address - Street 1:7620 N UNIVERSITY
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614
Mailing Address - Country:US
Mailing Address - Phone:309-693-0043
Mailing Address - Fax:309-693-0422
Practice Address - Street 1:7620 N UNIVERSITY
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614
Practice Address - Country:US
Practice Address - Phone:309-693-0043
Practice Address - Fax:309-693-0422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190136461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty